This invention relates to medical record documentation and calculating codes from that documentation thereby improving the consistency and the quality of medical care.
Billing for a physician's services has become increasingly more complex in recent years. Medicare requires that a code be assigned to each patient encounter, the interaction between a patient and the physician, assistant, nurse or other health care provider to evaluate the patient's medical problem. These codes encompass the complexity of the problem evaluated, the amount of work required of the physician and the level of detail required in both the history and physical portions of the examination. A third-party payor is an organization, carrier or intermediary that supplies insurance, especially health insurance (including Medicare), to individuals.
The American Medical Association in conjunction with the Health Care Financing Administration (HCFA) has developed a system of codes for the purpose of describing physician work for medical and surgical procedures, diagnostic tests, laboratory studies, and other physician medical services rendered to clients. This system of codes is generally referred to as Current Procedural Terminology, or CPT, codes. They provide a uniform language that details medical, surgical, and diagnostic services utilized by physicians to communicate to third-party payors the services that are rendered.
The Evaluation and Maintenance (E/M) codes are a sub-set of the CPT codes that are used to describe the patient encounter in an office, hospital or other setting. E/M codes are used to describe the level of care (work) a physician renders to a patient. The three key components of an E/M code are history, examination and medical decision making preformed by the provider during an encounter. E/M and CPT codes are revised yearly by the American Medical Association.
The World Health Organization developed a similar method to identify medical diagnoses, conditions and injuries. These codes are International Classification of Diseases 9th edition Clinical Modification (ICD9) codes. They are international codes, unlike the CPT codes which are national.
To manage this increasing complexity, groups such as Medicare Part B and independent companies such as the Physician Management Information Company (PMIC) have developed categorizations of various parts of the patient encounter. These aids usually take the form of checklists on letter or legal sized papers. They are often several pages long and serve to aid the provider in choosing the accurate level of service.
Some individuals have created small (generally 3'.times.5') cards that some physicians carry in pockets detailing the levels of service and the requirements for each level to insure accurate billing. The card has a general summary of the rules for a particular insurance payor. While providing easier access for the physician than the full size checklists or outlines, these cards provide only general guidelines. Many of the guidelines do not have concrete documentation guidelines. A physical examination, for example, may range from "problem focused" to "comprehensive." The more specific descriptions and examples are found in the CPT manual and several bound texts. These texts may not be easily accessible during the encounter. Moreover, they may not be used to verify a code description until after the encounter is over and the patient has gone home.
Additionally, some professional coders have developed their own plans for classifying the encounters into the appropriate code. These plans usually consist of lists or outlines and chart abstractions. They are applied to the documentation, usually after the encounter is completed, before billing the claim to the insurance carrier.
CodeLink is a software package developed by Context Software Systems, Inc. that compares the CPT code typed by the user to the ICD9 code or codes or vice versa. The two codes are compared based on the medical necessity established by HCFA. The codes are not generated as part of the real-time documentation process, but CodeLink is used as a separate, stand-alone reference after the encounter.
Documation is a software package used for medical documentation and OcuChart is the ophthalmology specific documentation software. Both were developed by Documation Inc. This software has a built-in ICD9 coding system. It does not calculate the E/M codes for billing a level of service.
PRISM is another software package that documents the medical encounter. It was developed by PRISM Data Systems, Inc. PRISM's Patient Registration module prints a list of CPT, E/M, and ICD9 codes selected by the physician. This list is not patient-specific. PRISM also does not calculate E/M codes or other service codes.
None of the known prior documentation code-linkage approaches are able to actually accomplish the long-felt needs of: deriving accurate calculated codes during the documentation process, calculating codes that are as accurate as possible, and doing this in an easy-to-use manner for the provider. Once the coding can be accomplished consistently, the billing process becomes routine. These problems are not limited to a particular medical specialty, but are common to both general practitioners as well as specialists and to a growing group of other limited medical practitioners and insurance payors. Medical specialists are defined as physicians who have chosen to concentrate their interest on one of the body systems or other medical groupings.
It is thus an important object of the present invention to provide the ability to generate codes based on the amount of work performed to describe the patient encounter. Medicare and other third-party payors are increasingly relying on a system of codes to describe the patient encounter. These codes are definable. The original definitions of these codes are contained in a variety of cumbersome texts. Some physicians use one of the shortened aids that are sometimes several pages long. Shorter, pocket sized versions may not completely define all the coding rules and regulations. Even the smallest method presents some degree of intrusion during the physician-patient encounter. The invention incorporates the desired coding scheme into the documentation of the encounter by the provider of services or anyone using the invention.
A further object of the invention is consistent coding. Most of the rules on the checklists and pocket cards are general rules. The invention incorporates rules for each third-party payor into a series of criteria. Specific criteria for each code are met or not met. The codes will then not vary due to differing interpretations. By tying the definition to the actual documentation, the invention provides a more reliable means of coding the encounter and a sense of security for the provider that an accurate code has been billed based on "medically necessary" guidelines.
Another object of the invention is to provide accurate coding. The invention allows derived codes such as E/M codes to be measured objectively. The criteria may be manipulated to give a precise definition for any code. The codes describing the overall encounter are more valid. Accuracy is also a factor when assigning procedural and diagnosis codes like the ICD9 and CPT codes. Human error may factor into any process where numbers are looked up in one source and transcribed into another. The system also allows the physician to select the textual descriptions of terms as an integral part of documenting the encounter. The descriptions are automatically attached to the appropriate code number(s).
A further object of the invention is to provide real-time calculations of the code during the patient encounter. Many of the checklists and other aids are used by the physician or other coder after the encounter: history, examination, medical decision making is completed. The invention calculates the codes as each portion of the encounter is entered into the documentation system. This concurrent calculation assures greater accuracy, consistency and is time-efficient for the physician.
Another object of the invention is to provide additional patient interaction time for the physician. The physician is freed from many medical record keeping tasks allowing for more time for interaction with the patient and family.
Still another object of the invention is linkage of the procedure(s) performed and diagnosis (why the service was rendered) to determine medical necessity. While CodeLink compares ICD9 and CPT codes and determines whether "medically necessity" was established, it does not determine any of the E/M codes or the ophthalmology codes (both are subsets of the CPT codes). This invention gathers the ICD9 and CPT codes during the encounter. This allows the physician or the office staff to save time by not having to look up each ICD9 or CPT code number in the ICD9-CM. Additionally, the medical necessity is determined during the encounter when the procedure is ordered, not after it is preformed, potentially decreasing the number of claims disallowed for not meeting the medical necessity criteria.
An additional advantage of the invention is the printing of a customized summary of the diagnoses, procedures and tests rendered to the patient, including E/M or established ophthalmology code calculated during the encounter. PRISM prints a physician-specific list, but not a patient specific list and does not calculate the E/M or established ophthalmology codes.
Further objects and advantages of this invention will become apparent from a consideration of the drawings and ensuing description. It is further to be understood that many changes and modifications of the embodiment of the invention as hereinafter described may be had without departing from the spirit of the invention as defined in the appended claims.